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1301 eNals Street-Suite 300 PLACEMENT FORM FOR SERVICE CALL BRANCH MANAGER - <br /> COLUMBIA,SOUTH CAROLINA 29201 a <br /> 09-545-1011 ERR VANBERGEN P000232809 . <br /> Ialegdlleeo. <br /> GUNS NO.05-397-6551 FED.ID NO.75-2178928 NAME TITLE SIGN <br /> GENERATOR LOCATION .BILL TO(IF DIFFERENT FROM LOCATION) 1CCLLI. <br /> &A OXF67K� C 2 <br /> Q / 10 SIC CODE <br /> BUSINESS CHAIN IATI SVC.P/C I PROD.P/C <br /> TYPE <br /> I ISI I I� <br /> SALES TAX EXEMPTION NUMBER <br /> SERVICE TAX C.O.M.S,TAX PRODUCT TAX <br /> -DATE PLACED SALESREPNO. ❑BLANKET ❑TEMPORARY CUSTOMER PHONE NO. �aE cGDE .y <br /> CUSTOMER'S J / <br /> /f96 PO.NUMBER r <br /> ' - US <br /> SALES TOTAL SOLVEM/DRUMIS sEmncE SCHE ULE FrzE Irry PROMO RELEASE <br /> DEPT SERVICE/ SERIAL REMARKS/UNIT PRICE OUM`I. CHARGE TAX ''CHARGE SK DO'." T� esion N0. NO. <br /> PRODUCT NUMBER <br /> ❑ <br /> 2 El <br /> 3 <br /> El4 <br /> 5 <br /> 6 <br /> 7 y/y 7•�.yJ REFUSED SERVICE EZPIN (tn)NEwnRPu <br /> TOTAL-SERVICE/PRODUCTS q47 2 $:r_ <br /> REPACECuEFnELa.'NIN <br /> E FNLHINE <br /> (3)RBP.FCE LYk.PEIITNE M�GIINE <br /> CODES (<)RFAACE HQ.E MADE VAT. <br /> USEPATRANSPORTERIIDNO. USEPATRANSPOMM21DN0. GENERATOR USEPA ID NO. GENERATOR STATE ID NO. (61ADdnOHAL MAWPE <br /> LD984908202CERTI HT MY TOTAL <br /> 12.C0 AINERS 13. TOTAL 14.UNI SK DOT NUMBER51 3 55 <br /> 11.US DOT DESCRIPTION (INCLUDING PROPER SHIPPING NAME,HAZARD CLASS,AND ID.) No. TYPE DUANTITv wrmoL WASTE STREAMS ARE WITHIN <br /> CATEGORIES HE FOLLOWING <br /> W STE COMBUSTIBLE LIQUID, N. O. S. ( PETROLEUM NAPHTHA) NA1993 704 BTo 22o LesrooNTH <br /> 3III ( ERG#128 )6. 7#/GAL (DOO1, D018, D039 ❑040 <br /> W STE COMBUSTIBLE LIQUID, N. O. S. ( PETROLEUM NAPHTHA)NA1993 717 NI AB <br /> `III ( EAG#128 ) 6. 7LBS/GAL ( ❑039 220 LBS,TO 2.200LBS�ON <br /> W STE COMBUSTIBLE LIQUID, N. O. S. ( PETROLEUM NAPHTHA) NA1993 801 INITIALS <br /> III R ( DO18 )ERG 128 6. 7 /GL ) DO01 DO39. DO40 aEA ER wwa oB�mom <br /> INITIALS <br /> D. <br /> DESIGNATED FACILITY NAME AND ADDRESS SAFETY-KLEEN SYSTEMS, INC. USA EPA ID NO. <br /> STATE ID NO. p <br /> CASH TOTAL RECEIVED PPLV PAYMENT T MANIFEST NO. I AGREE TO PAY THE ABOVE CHARGES AND TO BE BOUND BY THE TERMS AND TOTAL CHARGE •�, Z <br /> CONDITIONS SET FORTH ABOVE AND ON THE REVERSE SIDE OF THIS DOCUMENT. (FROM ABOVE) ` <br /> CHECK NUMBER A DAYS SERVIOESALE � PLEASE CHARGE MY ACCOUNT FOR THIS TRANSACTION UNLESS OTHERWISE <br /> 7 INDICATED IN THE PAYMENT RECEIVED SECTION.THE INDIVIDUAL SIGNING THIS TOTAL DUE d <br /> L t PRFA 5B EABFIX O B <br /> ❑ LDR MESSAGE DOCUMENT IS DULY AUTHORIZEDTO SIGN AND BIND CUSTOMER TO ITS TERMa, <br /> to urvh,n.ILA•ews^•me^m•x^,m:.-^^x^+a'..m.°.e'w'sz°,'^`^"°'"°I.°"`°.a^a ue^ DO NOT WRITE IN AREA BELOW <br /> INVOICE% AMOUNTS INVOICE III AMOUNT$ Pwv w�e�ro^Id,a^.w�ular�m�ns lome,Niaea a�wu^^.mu,oro• mwra,re,onalbn <br /> MANIFEST CODE SEON 7 <br /> PREVIOUS - --' �/' �L,h /-o,i7r' <br /> CREDIT 3 D- PrinlCusl7 Name P000232809 <br /> CARD N <br /> AMEX <br /> OF rt�viryo �- f� 015963 <br /> EMEMC By <br /> Cusfomefs Authonzatl Representeiive <br /> CUSTOMER REFERENCE1-800468-1760 THIS AGREEMENT CONTINUES ON THE REVERSE SIDE <br /> INFORMATION <br />